Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of Arcola during CMS and state inspections, most recent first.
Failure to protect residents from abuse: one resident with schizoaffective disorder was witnessed squeezing another resident’s breast and making sexually explicit comments, while another incident involved a cognitively intact resident slapping a confused resident multiple times during a hallway altercation. The records also showed both residents had behavior issues, including aggression, wandering, paranoia, and poor social boundaries.
Failure to provide a 30-day notice for an involuntary discharge. A cognitively intact resident with schizoaffective disorder exited the facility through an unsecured door, was found several blocks away, and was transported to the ED with hypothermia. While the resident was in the hospital, the DON and Social Service Designee delivered involuntary discharge papers. The Administrator stated the discharge was issued because the unit was not locked and the resident needed locked doors to prevent leaving on his own.
Failure to Implement Dementia Wandering Interventions: A resident with dementia, schizophrenia, memory impairment, and wandering behavior had a care plan calling for structured activities and reorientation aids such as signs, pictures, and memory boxes. However, staff did not place any room-identifying cues near the resident’s doorway, and a CNA confirmed these interventions had not been used. The resident continued to wander into other residents’ rooms, and an altercation occurred when another resident struck the wandering resident after the resident grabbed a wheelchair armrest.
Failure to document a resident-to-resident altercation in the EMR. Two residents were involved in an incident where one resident slapped the other during a confrontation, and a CNA witnessed the event. The LPN, DON, and Administrator confirmed the altercation was handled in risk management but was not documented in either resident’s EMR, despite the facility’s Abuse Prevention Policy stating all incidents will be documented.
A resident with a history of falls, recent hip replacement, and moderate cognitive impairment was not safely assisted by a CNA during a weighing procedure. The CNA failed to follow proper protocol when maneuvering the resident's wheelchair on a sloped scale ramp, resulting in the resident falling forward out of the wheelchair and sustaining a lumbar vertebral fracture. Staff and the DON confirmed that the incident was due to improper handling during the transfer.
The facility failed to provide RN coverage for eight consecutive hours every day as required by policy. Staffing records showed missed RN coverage on multiple days, and the 24-hour staffing sheet documented no RN scheduled for an entire day. The Administrator confirmed the lack of RN coverage, and the facility stated it accepts residents with clinically complex conditions and provides RN services.
Failure to Monitor and Care Plan Recurrent Hyponatremia: A resident with moderate cognitive impairment and multiple psychotropic medications had repeated episodes of hyponatremia with several hospitalizations for low sodium, altered mental status, and related conditions. The record showed ordered CMPs were not documented as completed, there were no routine sodium monitoring orders, and the care plan did not address the recurring hyponatremia. Staff and the DON confirmed the only intervention in place was monthly IV vitamin infusions, while the NP stated the low sodium was likely related to psychotropic meds.
Failure to follow EBP, hand hygiene, and equipment disinfection requirements occurred for multiple residents. Staff did not wear gowns and gloves for a resident with a urinary catheter and MDRO history during high-contact care, did not keep the catheter bag off the floor, and did not perform hand hygiene before and after catheter care. A RN also accessed another resident's feeding tube without a gown, and an LPN cleaned scissors used during wound care with soap and water only after cutting packing for a draining stage IV pressure ulcer.
A resident with normal cognition and a care plan for supervision and partial assistance with bathing said she did not want a male CNA helping with showers because he did not get her clean. Despite her stated preference for female staff, record review showed she received multiple showers with the male CNA, and the DON said the resident had the right to choose who assisted her.
Failure to Provide Quarterly Personal Funds Statements: The facility did not provide or document quarterly statements for two residents with personal funds accounts. One resident and the resident’s guardian reported not receiving the statements, and another cognitively intact resident responsible for her own finances also stated she did not receive them. The BOM stated statements were given quarterly or upon request, but the facility had no documentation of delivery or resident acknowledgment.
Missing Written Transfer and Bed Hold Notices: A resident with multiple hospitalizations did not have documentation of written transfer and bed hold notices for two hospital transfers. The facility policy required written notification at the time of transfer, and the EMR contained notices for other hospitalizations but not for the two identified events. An LPN and the DON described how the notices are typically documented and provided, but the DON confirmed the missing documentation.
Failure to assess, measure, and treat a resident’s pressure ulcer consistently. A resident with quadriplegia and other serious diagnoses had a wound documented on the right gluteal fold, but skin assessments were left blank or lacked measurements, and staff documented inconsistent wound locations as the right upper thigh and right gluteal fold. The wound NP recorded the pressure ulcer worsening from stage III to stage IV, while QA notes showed the treatment in place was not the correct order and later wound care found the wound draining large amounts of gray-brown liquid and odorous.
Missing CPAP Orders and Documentation: A resident was observed with a CPAP machine, mask, and tubing at the bedside, but there were no physician orders for CPAP settings and no charted CPAP use or cleaning in the record. The resident said staff did not provide CPAP care, and staff interviews showed the LPNs, CNA, and DON were not aware the resident was using CPAP or when it began.
Physician visit notes were not documented for one resident whose primary MD was unable to provide a dated progress note in the EMR. The resident had multiple hospitalizations over the past year, but the chart contained only specialist and NP notes. The ADM could not locate the MD’s notes or confirm the last visit, and the MD stated he keeps his notes separately and could not find any notes for the resident.
Failure to Document Timely Physician Visits: The facility failed to ensure a resident received timely MD visits. The resident’s EMR had no physician progress notes from the attending MD for the past year, only specialist and NP notes. The Administrator could not locate the notes or say when the resident was last seen, and the MD stated monthly rounds occur but not every resident is seen each month and could not provide the last visit date or progress note.
Failure to Track Antibiotic Use and Infection Details: A resident’s infection and antibiotic treatment were not fully documented in the facility’s surveillance log. Records showed a contaminated urine culture, treatment with multiple antibiotics, and later hospital documentation of UTI with MRSA, but the monthly infection reports did not consistently list the UTI, organism, or antibiotic use, and one antibiotic course was recorded as being for an unknown infection.
Two residents with mental health conditions experienced repeated breaches of privacy when one resident, who is cognitively intact but exhibits intrusive behaviors, entered others' rooms and opened privacy curtains during personal care. Staff confirmed ongoing difficulties in redirecting the resident, and the DON acknowledged these actions violated privacy rights.
Two residents with cognitive and behavioral health diagnoses were involved in repeated incidents of verbal abuse, including threats and derogatory language. Staff and administrator interviews confirmed that one resident verbally threatened and harassed another, and the facility did not effectively intervene to prevent or address the abuse, despite documented care plans outlining the risks and required interventions.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Three cognitively intact residents experienced a failure of dignity when one resident, who requires a wheelchair and supervision, was inappropriately touched by another resident in a common area. The incident was witnessed by another resident and confirmed by an LPN. The care plan for the affected resident did not address behaviors related to sexual conduct, and both residents involved required constant supervision on a locked psychiatric unit.
A resident with a history of mental health issues verbally threatened and intimidated other residents, causing fear and distress. Despite staff awareness, the facility failed to prevent these incidents, resulting in a deficiency in protecting residents from verbal abuse.
The facility failed to report verbal abuse incidents involving three residents to the Abuse Coordinator, as required by policy. An LPN witnessed a resident threatening another during supper but did not report it, assuming the administrator would be informed. A Social Service Assistant was aware of another altercation but did not report it separately. The administrator confirmed staff did not follow the facility's abuse policy.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. On several occasions, no RN was scheduled, and on one occasion, an RN was present for only four hours. The administrator acknowledged the staffing issue, which affected 69 residents in the SNF-certified facility.
An LPN failed to perform hand hygiene during medication administration for multiple residents, leading to potential cross-contamination. Despite facility policy requiring handwashing or the use of alcohol-based hand rub (ABHR) between residents, the LPN did not adhere to these guidelines, touching various surfaces without using ABHR. The LPN acknowledged the oversight, and the Regional DON confirmed the necessity of hand hygiene between residents.
A facility failed to obtain a new Level 2 PASRR for a resident with Paranoid Schizophrenia after the initial evaluation expired. The resident required specialized mental health services, but the facility lacked documentation of a more recent assessment, and the screening agency had no records of an updated evaluation.
A facility failed to complete a baseline care plan within 48 hours for a resident admitted with multiple medical conditions, including a wedge compression fracture and dementia. The resident's care plan lacked necessary focus areas, goals, and interventions before the resident experienced a fall. Staff interviews revealed a lack of awareness about the required timeframe for completing baseline care plans.
A resident experienced falls and was supposed to have an alarm on her wheelchair as a post-fall intervention. However, during an observation, it was found that the alarm was missing, with only the power cord present. An LPN confirmed the absence of the alarm, indicating a failure to implement the care plan.
A resident with a history of movement disorder and dementia was found to have a loose bed side rail, which was used for mobility and transfers. The rail was observed to be excessively loose, with a gap exceeding FDA safety guidelines, and the resident expressed concern about its condition. An LPN confirmed the need for replacement due to the safety risk.
A resident with severe cognitive impairment hit another resident during breakfast after the latter grabbed the former's oatmeal. The incident was witnessed by staff and another resident, confirming the action was intentional. The resident who was hit had memory loss, and no injury was noted. The facility's policy affirms residents' rights to be free from abuse, yet this incident affected three residents reviewed for abuse.
A facility failed to report an alleged abuse incident where a resident reported feeling afraid after another resident grabbed their wrist. Despite the resident informing a CNA, the incident was not reported to the administrator as required by the facility's Abuse Prevention Program.
A resident was mistakenly given another resident's medications due to a room change that was not properly communicated, resulting in an emergency room visit for an accidental overdose. The facility's policy requiring verification of resident identity was not followed, leading to the administration of medications not prescribed for the resident.
The facility failed to document interventions for five residents reviewed for abuse, despite having an abuse prevention policy. Interventions such as separating residents and relocating activity carts were identified but not recorded in medical records, as confirmed by the administrator.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents, including physical and sexual abuse. One incident involved a resident with schizoaffective disorder who was cognitively intact and ambulatory with supervision, and who had a care plan noting aggressive behavior and inappropriate statements. A CNA witnessed this resident standing behind another resident with severe dementia, major depressive disorder, and dysphagia, and squeezing the other resident’s left breast in the dining room. The CNA reported that the resident making the contact stated, “Leave me alone it makes me aroused squeezing her breast,” and said the resident knew what he was doing. Another CNA had previously heard the same resident ask to see her breasts and reported that statement to the charge nurse. The administrator stated the other resident was moved to another unit because of the incident. A second incident involved two residents when one resident struck another resident on the arm during an altercation in the hallway. The resident who struck the other was cognitively intact and had care plan problems related to suspiciousness, paranoia, anxiety, agitation, verbal outbursts, yelling, demanding behavior, hateful or inappropriate comments, and mocking others. The other resident had memory impairment, moderate impairment in daily decision-making, dementia, paranoid schizophrenia, and a care plan noting wandering, violating personal space, not comprehending social limits, and possible combative behavior. Witness statements and interviews showed the resident who was struck did not hit first; instead, the resident who initiated the contact slapped the other resident multiple times after the other resident grabbed the wheelchair armrest while passing in the hallway. The report also noted the second resident wandered into other residents’ rooms and lay in their beds, and the first resident stated the other resident had entered her room before and hit her arm.
Failure to Provide 30-Day Notice for Involuntary Discharge
Penalty
Summary
The facility failed to provide a 30-day notice for an involuntary discharge for one of one resident reviewed for involuntary discharge. The facility’s Immediate/Emergency Transfer and Discharge Policy dated September 2016 states that resident transfers and discharges are to be conducted in accordance with residents’ rights, physician’s orders, and in a manner that maintains continuity of care. The resident’s Physician Order Sheet dated November 2025 documented diagnoses of Schizoaffective Disorder, Varicella without complications, and Drug Induced Subacute Dyskinesia. The resident’s MDS assessment documented a BIMs score of 15, indicating the resident was cognitively intact. The Facility Incident Report Final Report dated 11/15/25 documented that the resident exited the building on 11/10/25 at 5:10 AM through the Southwest exit door and was found in a field about three blocks from the facility at 6:15 AM. EMS transported the resident to the ED, where the resident was diagnosed with hypothermia. A progress note dated 11/12/25 documented that the Social Service Designee and Administrator delivered involuntary discharge papers to the resident while at the hospital. During interview, the Administrator stated the resident was given involuntary discharge papers because the facility is not a locked unit and the resident needs locked doors to prevent exiting on his own. The resident’s brother stated the resident had been at the facility for over 20 years and could barely talk due to a speech problem. Hospital staff stated the facility served the resident papers for an involuntary discharge, that the resident was alert and oriented but could not live alone or care for himself, and that the Ombudsman was helping with the discharge process.
Failure to Implement Dementia Wandering Interventions
Penalty
Summary
The facility failed to implement care planned interventions for a resident with dementia-related wandering behavior. The resident’s MDS documented short- and long-term memory impairment, moderate impairment in cognitive skills for daily decision making, and wandering. The active care plan identified diagnoses of dementia and paranoid schizophrenia and included a problem that the resident wandered the hallways, entered other residents’ rooms, and got into unoccupied beds. Planned interventions included structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes. During observation, the resident was sitting in a recliner in the room and responded to name only, without answering questions. There were no pictures, memory boxes, or signs in or near the doorway to help the resident identify the room; only a standard name plate with the resident’s first initial and last name was present, the same format used for all residents. A CNA stated the resident wanders into other residents’ rooms and is on 15-minute visual checks, and confirmed that signs, pictures, and shadow boxes had not been used for this resident. The report also documents an incident in which another resident smacked the wandering resident’s arm after the wandering resident grabbed the other resident’s wheelchair armrest, with witnesses stating the wandering resident commonly goes into other residents’ rooms and lies in their beds.
Failure to Document Resident-to-Resident Altercation
Penalty
Summary
The facility failed to document a resident-to-resident altercation in the electronic medical record for two residents reviewed for abuse. The State of Illinois Department of Public Health Long-Term Care Facility & IID - Serious Injury Incident Report dated 10/23/25 documented that on 10/16/25 at 2:20 PM, one resident open-handed smacked another resident on the right upper arm. The report stated the first resident said the action was in retaliation and claimed the other resident hit first, but witnesses did not support that claim. The residents’ EMRs did not include documentation of the altercation. One resident later stated that the other resident gets into people’s rooms and sleeps in their beds, and described a prior physical incident in which the other resident banged on the resident’s arm and the resident banged back. A CNA confirmed witnessing the altercation and described the first resident as alert and oriented, while the other resident was confused and in her own world. The LPN stated the incident was handled in risk management and that only supervision changes were documented, while the DON and Administrator confirmed the altercation was not documented in either resident’s EMR. The facility’s Abuse Prevention Policy stated all incidents will be documented, whether or not abuse occurred, was alleged, or suspected.
Failure to Safely Assist Resident During Weighing Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls, significant medical history including a recent right hip replacement, spinal stenosis, osteoarthritis, and moderate cognitive impairment, was not safely assisted during a routine weighing procedure. The resident, who required substantial to maximum assistance with transfers and used a manual wheelchair, was being weighed on a platform scale with a sloped ramp. The Certified Nursing Assistant (CNA) assisting the resident backed the wheelchair onto the scale and, after weighing, pushed the wheelchair forward down the ramp, allowing the resident to face forward. As a result, the resident fell forward out of the wheelchair and sustained a vertebral fracture. The incident was witnessed, and it was documented that the resident hit his head and complained of pain on the right side. The resident was on blood thinners and had a history of falls, including a recent hip fracture at home that led to his admission for rehabilitation. The facility's own staff and the resident confirmed that the usual and safe practice was to push the wheelchair up the ramp facing forward and to pull the resident backwards down the ramp to prevent forward falls. However, on this occasion, the CNA did not follow this protocol, resulting in the resident's fall and injury. Interviews and record reviews revealed that the resident had experienced other falls in the facility, some due to self-transferring, but the fall during the weighing procedure was attributed to staff error. The facility's Director of Nursing and other staff acknowledged that the improper handling of the wheelchair on the scale ramp directly led to the resident's fall and subsequent lumbar fracture. The facility's fall prevention policy emphasized the need for an environment free from hazards and appropriate supervision, which was not adhered to during this incident.
RN Coverage Not Provided for Required Daily Shift
Penalty
Summary
The facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every 24 hours. The facility’s Staffing Policy states that an RN will be scheduled seven days a week at least one continuous 8-hour shift, but the nursing work schedule for August 2025 and September 2025 showed no RN coverage for eight consecutive hours on 8/25/25, 8/30/25, and 9/10/25. The 24-hour staffing sheet for Wednesday, September 10, 2025 documented that no RNs were scheduled during that 24-hour period. The facility assessment stated that the facility accepts residents with a variety of clinically complex conditions and that RNs are provided by the facility. On 9/09/25, the Administrator confirmed there were no RNs on duty for eight consecutive hours on 1/1/25, 3/31/25, 8/25/25, and 8/30/25, and later confirmed there were no RNs on duty for eight consecutive hours on 9/10/25. The Long-Term Care Facility Application for Medicare and Medicaid documented that 65 residents resided at the facility.
Failure to Monitor and Care Plan Recurrent Hyponatremia
Penalty
Summary
The facility failed to develop and implement interventions and monitoring for a resident with recurring hyponatremia and repeated hospitalizations. The resident had moderate cognitive impairment and was receiving multiple psychotropic medications, including fluoxetine, mirtazapine, olanzapine, divalproex, and clorazepate dipotassium. An emergency room discharge instruction documented hyponatremia with a sodium level of 128 and directed follow-up with the physician and recheck of sodium because some seizure medications and antidepressants can affect sodium levels. The resident was later hospitalized after a fall with acute on chronic hyponatremia, urinary tract infection, and pneumonia, and was treated with IV normal saline. Hospital documentation later noted syndrome of inappropriate antidiuretic hormone secretion that improved with fluid restriction. Physician orders were written to obtain CMPs, and a progress note later documented a recheck CMP, but there was no documentation that the ordered CMPs were completed; the record showed only one CMP completed later. The resident was hospitalized again with altered mental status and a sodium level of 120, and later hospitalized again with urinary retention, altered mental status, lethargy, and hyponatremia with a sodium level of 125. The resident’s active care plan did not address recurrent hyponatremia, and the active physician orders did not include routine lab monitoring. Staff stated labs were done on readmission and as ordered, but the DON confirmed there were no routine sodium monitoring orders and that the only intervention was monthly IV vitamin infusions. The DON also confirmed the care plan did not address hyponatremia and that ordered sodium checks after hospital discharge and on 5/21/25 were not documented as completed. The nurse practitioner stated the hyponatremia was likely related to psychotropic medications, that the resident’s psychiatric medications should not be adjusted, and that monthly BMP monitoring was later ordered after the concern was discussed.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions, perform hand hygiene, properly disinfect equipment, and keep a urinary catheter drainage bag off the floor for three residents. R40 had a urinary catheter, a history of urinary tract infections, and had been admitted to the hospital for a UTI with methicillin resistant staphylococcus aureus. Although a sign on R40's door indicated EBP and PPE was available, staff did not wear gowns and gloves for high-contact care such as transfers, dressing, linen changes, walking assistance, and catheter-related care. Staff also did not perform hand hygiene before or after catheter care, and R40's catheter drainage bag was observed on the side of the bed and later touching the floor during care. Staff stated they were not aware of EBP requirements or believed gowns were only needed for catheter-related care. For R43, a sign on the door indicated EBP, but a RN accessed the feeding tube without wearing a gown. For R12, wound care was performed for a tunneling stage IV pressure ulcer with large amounts of gray-brown drainage and odor. During the wound care, the LPN donned gown and gloves, removed and replaced packing, and cut iodoform gauze with scissors kept in the room. The scissors were then taken to the utility room and cleaned with soap and water only, and the LPN stated a bleach wipe should have been used.
Failure to Honor Resident Preference for Female Shower Assistance
Penalty
Summary
The facility failed to honor a female resident’s request to have her showers provided by female staff. The resident had normal cognitive function with a BIMS score of 15 and stated that she did not want a male CNA assisting with her shower because he did not get her clean. She reported that she told a CNA about her preference and was told she would have to take her shower in the evening if she did not want the male CNA helping her, which she agreed to, but she said nothing changed. The resident’s MDS documented that she required supervision or touching assistance with bathing, and her care plan documented the need for supervision with ADLs and partial assistance with showering. A 30-day review of the electronic record and shower sheets showed that she received showers with help from the male CNA on multiple occasions. The DON stated that it was the resident’s right to choose who helped with showers and said she was not aware the resident wanted only female staff assisting with showers.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements of personal funds accounts for two residents, R4 and R8, whose money was deposited with the nursing home. The facility’s Quarterly Trust Statements Policy stated that quarterly statements are to be sent by the last day of the following month, with copies kept for records, a spreadsheet maintained to show when statements were mailed, resident or representative signatures obtained to show receipt, and copies uploaded into the electronic medical record. However, the business office manager stated that statements were provided quarterly and upon request, but documentation of when they were provided was not being kept and residents were no longer signing to acknowledge receipt after the facility changed ownership. R8 stated that money was in a personal funds account but that R8 did not know how much was in the account and did not receive quarterly statements. R8’s guardian confirmed that R8 had a personal funds account and said billing statements were received, but was unsure whether quarterly personal funds statements were sent. R8’s statement showed an accounting of deposits, withdrawals, and interest, but there was no documentation showing when quarterly statements were sent to the guardian. R4, who was documented as cognitively intact and responsible for her own finances, stated that she had money in a personal funds account but did not know how much was in the account and did not receive quarterly statements. R4’s statement also showed an accounting of deposits, withdrawals, and interest, but there was no documentation showing when quarterly statements were provided.
Missing Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer and bed hold for one resident who was hospitalized multiple times. The facility’s Bed Hold and Readmission Policy dated November 2016 states that residents or their representatives are to be informed of the policy on admission and at the time of transfer to a hospital, and provided written notification at the time of transfer. The policy also states that in an emergency hospitalization, the resident or representative may be notified by telephone and may verbally give the bed hold determination, with documentation in the progress notes and possible follow-up written confirmation. During interview and record review, the resident stated they went to the hospital 3 to 4 times per year. The resident’s record showed hospitalizations on 4/15/25 and 7/18/25, among others. The electronic medical record did not contain documentation that written notice of transfer and bed hold was provided for the 4/15/25 and 7/18/25 hospitalizations. The LPN stated the notices are documented in the assessments tab and printed and given to the resident upon discharge to the hospital. The DON stated the notices are provided upon discharge and may be faxed to the hospital in an emergency transfer, and that they are documented in the assessments or uploaded into the miscellaneous section of the EMR. Written notices were provided for other hospitalizations, but the DON confirmed there was no documentation of written bed hold/transfer notice for the two identified hospitalizations.
Failure to Assess, Measure, and Treat a Resident’s Pressure Ulcer Consistently
Penalty
Summary
The facility failed to assess and measure a pressure sore, follow physician-ordered wound treatment, and accurately document the wound location for one resident with multiple serious diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, seizures, and other chronic conditions. The resident’s admission skin assessment documented a superficial wound on the right gluteal fold measuring 0.2 cm by 0.2 cm by 0 cm, but subsequent skin assessment tools were incomplete or blank, including one dated 4/28/25 and another dated 5/12/25. A 5/7/25 skin assessment documented continuation of Mepilex treatment to the right gluteal fold but did not include measurements, and the administrator and corporate RN verified that no wound assessments were completed on 4/28/25 or 5/12/25 and no measurements were documented on 5/7/25. The physician’s orders also reflected inconsistent wound location documentation, with one order listing the right upper thigh and another listing the right gluteal fold. The wound care NP documented the wound as a stage III pressure ulcer on the right gluteal fold with progressive increases in size and depth over time, later documenting it as a stage IV pressure sore with tunneling. The facility’s quality assurance notes documented that the wound treatment in place was not the correct treatment per order, and staff later stated the wound had been charted by some as the right upper thigh and by others as the right gluteal fold, but it was the same wound. At the time of wound care on 9/9/25, the wound was draining large amounts of gray-brown liquid and was odorous.
Missing CPAP Orders and Documentation
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who was observed with a CPAP machine on an overbed table next to the bed, with the CPAP mask and tubing stored in a plastic bag attached to the machine. The resident stated they had been in the facility for a few weeks and used the CPAP at night, and also stated staff did not do any care for the CPAP. The resident’s active physician orders did not include any CPAP orders, and there was no documentation in the medical record of CPAP use or care/cleaning. Staff interviews showed the resident’s CPAP use was not known to multiple staff members. An LPN stated they were not aware the resident was using a CPAP, while another LPN stated the resident was not using a CPAP when first admitted and was unsure when CPAP use began. The second LPN also stated night shift documents CPAP care on the TAR. A CNA stated the resident had been using the CPAP for a few nights. The DON stated CPAP masks should be cleaned weekly with soap and water and that there should be a physician order for CPAP settings, but was not aware the resident had a CPAP.
Physician Visit Notes Not Documented
Penalty
Summary
The facility failed to ensure physician visits were documented for one resident, R40, who has resided in the facility since 2004 and whose primary physician is V21. The resident’s active census showed six hospitalizations within the last year, but the electronic medical record contained no physician visit notes by V21 during that period, only specialist and nurse practitioner notes. The facility’s Physician Services Policy states that the attending physician shall write a progress note at each resident visit and review the resident’s total program of care, including comprehensive assessments, care plans, medications, and treatments, with approval by signing and dating the current order recap. On interview, the Administrator stated the facility could not locate R40’s physician progress notes and was unsure when R40 was last seen by V21. V21 stated he keeps his progress notes separately and does not document visits in the electronic medical record, and although the facility requested R40’s physician visit notes, none could be located. V21 also stated he had evaluated R40 but could not provide a specific date or the last physician progress note, and a search of R40’s name in the database did not find any notes.
Failure to Document Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits for one of three residents reviewed for hospitalizations, R40. The facility’s Physician Services Policy states that each resident is under the care of a physician licensed in the state and that physician services will comply with State and Federal regulations. The policy also states the attending physician shall write a progress note at each resident visit, review the resident’s total program of care, and certify upon admission and at each visit every 30/60 days thereafter what level of care the resident requires. R40 has lived in the facility since 2004 and V21, the Physician/Medical Director, is listed as the primary physician. The active census showed that R40 was hospitalized six times within the last year. However, R40’s electronic medical record did not contain any physician visit notes by V21 within the last year, only specialist and nurse practitioner notes. The Administrator stated that no physician progress notes by V21 could be located and was unsure when R40 was last seen by V21. V21 stated that monthly rounds are done at the facility but not every resident is seen each month, and although V21 believed R40 had been evaluated, V21 could not provide a specific date or locate R40’s last physician progress note.
Failure to Track Antibiotic Use and Infection Details
Penalty
Summary
The facility failed to log infections, organisms, and antibiotics and failed to ensure the appropriate antibiotics were administered for one resident reviewed for infection control. The facility’s Antibiotic Stewardship Program Guidelines stated that the program was intended to monitor antibiotic use and outcomes, and the Infection and Prevention and Control Program stated it was based on facility assessment and national standards to prevent, recognize, and control infection. For one resident, a urine culture dated 5/2/25 showed mixed flora with no sensitivity performed, and the Infection Preventionist stated the specimen was contaminated and that the resident was placed on cephalexin without repeating the urine test. The resident’s ER records showed CT findings of bladder inflammation and pneumonia, with initial treatment using vancomycin and Zosyn and later ceftriaxone added based on urine culture results showing a UTI. However, the facility’s May 2025 Infection Surveillance Monthly Report did not document any UTI or antibiotic use for the resident. The record also showed additional antibiotic-related documentation gaps for the same resident. The July 2025 Infection Surveillance Monthly Report documented ertapenem sodium starting on 7/7/25 for an unknown infection, and the Infection Preventionist stated the organism being treated was not confirmed and should have been documented on the surveillance log. Progress notes from 8/19/25 documented that the resident returned from the hospital with a diagnosis of UTI with staph/MRSA, and the monthly surveillance report documented Bactrim for UTI but did not include MRSA. The Infection Preventionist stated the resident did have a diagnosis of UTI with MRSA and that it should have been listed on the Infection Surveillance log, and provided case detail documenting MRSA of the urinary tract.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect the privacy and confidentiality rights of its residents, specifically affecting two individuals with significant mental health diagnoses. One resident, who is cognitively intact but exhibits behaviors such as attention seeking, repetitive questioning, invading personal space, and inappropriate comments, repeatedly entered other residents' rooms and personal spaces, with documentation showing 17 such incidents in the past 30 days. This resident was also noted to open privacy curtains while staff were providing personal care to another resident, thereby exposing that resident during vulnerable moments. Staff interviews confirmed that the resident's behavior was ongoing and difficult to redirect, with multiple staff members acknowledging the repeated invasions of privacy. The Director of Nursing was unaware of the specific incidents involving the privacy curtain but confirmed that such actions constitute a violation of the affected resident's right to privacy. The facility's own policy emphasizes the importance of protecting resident rights, including privacy and confidentiality, but staff interventions were insufficient to prevent these breaches.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from verbal abuse, as evidenced by multiple incidents involving two residents. One resident, diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia, exhibited behaviors such as attention seeking, repetitive questions, invading personal space, and making inappropriate comments. Another resident, diagnosed with Bipolar Disease, Anxiety, and Mild Cognitive Impairment, displayed behaviors including agitation, verbal outbursts, mocking, yelling, and making false allegations. Staff interviews confirmed that the second resident verbally threatened the first resident, including yelling expletives and making threats of physical harm. Staff also reported that the second resident frequently told the first resident to "shut up and go away." The care plans for both residents documented their behavioral challenges and the need for staff intervention to protect the rights and safety of others. Despite these documented needs, the facility did not prevent or adequately address the verbal abuse occurring between the residents. The administrator confirmed that the threats made constituted verbal abuse and acknowledged that the first resident's behaviors placed her at risk for such abuse. The deficiency was identified through interviews and record reviews, which demonstrated a failure to uphold the facility's abuse policy and protect residents from verbal abuse.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Resident Dignity During Inappropriate Contact Incident
Penalty
Summary
The facility failed to ensure resident dignity for three cognitively intact residents who were reviewed for dignity concerns. One resident, who requires a wheelchair for mobility and supervision with daily activities, reported that another resident approached her in a common area, rubbed her upper leg, and attempted to touch her perineal area. The incident was witnessed by another resident, who confirmed that the resident in question placed his hand on the inside of the first resident's lower thigh and moved it upwards, prompting the first resident to move away in her wheelchair. The staff member interviewed confirmed the sequence of events and stated that the resident who initiated the contact was sent to the emergency room for evaluation due to his behaviors. The care plan for the resident who was touched did not include any focus area, goal, or interventions related to behaviors of consensual sexual behavior with male peers prior to the incident. Both residents involved were documented as cognitively intact but required constant supervision and resided on a locked psychiatric unit. The facility's policy states that residents have the right to be treated with dignity and respect, but the lack of appropriate care planning and supervision led to a situation where a resident's dignity was not maintained.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by incidents involving a resident, R1, who verbally threatened and intimidated other residents, R2 and R7. R1, who has a history of depression, bipolar disorder, and other medical conditions, was involved in multiple altercations where he yelled and cursed at fellow residents. On one occasion, R1 threatened to kill everyone in the dining room, causing fear among residents and staff. R2, who was present during the incident, reported feeling scared and noted that R1's behavior was aggressive and intimidating. Another incident involved R1 yelling at R7 to vacate a chair in the community dayroom, using threatening language. R7, who has schizophrenia and bipolar disorder, expressed feeling scared by R1's aggressive demeanor. The facility's staff, including LPNs and the administrator, were aware of R1's outbursts but failed to prevent these incidents or adequately protect the residents from verbal abuse. The facility's administrator acknowledged that R1's behavior was inappropriate and that the incidents were not initially recognized as abusive. The administrator later confirmed that R1's actions constituted verbal abuse towards R2 and R7. Despite the awareness of R1's behavior, the facility did not take immediate action to prevent further incidents, resulting in a deficiency in protecting residents from abuse.
Failure to Report Verbal Abuse Incidents
Penalty
Summary
The facility failed to report allegations of verbal abuse involving three residents to the Abuse Coordinator, as required by their policy. The policy mandates that employees report any incident, allegation, or suspicion of abuse immediately to the administrator or a designated individual in their absence. However, the facility did not document the reporting of a verbal altercation between two residents on December 23, 2024, nor did they report a separate incident involving another resident on December 21, 2024, to the State Agency. Interviews with staff and residents revealed that these incidents were not communicated to the appropriate authorities, as required by the facility's abuse prevention policy. In one incident, a resident was verbally threatened by another resident during supper, causing fear among the residents present. A Licensed Practical Nurse (LPN) witnessed the incident but did not report it, assuming the administrator would have been informed through other means. In another incident, a Social Service Assistant (SSA) was aware of a verbal altercation between two residents but did not report it separately, believing it would be included in the investigation of other incidents involving the same resident. The administrator confirmed that staff did not adhere to the facility's policy by failing to report these incidents, highlighting a breakdown in communication and adherence to established procedures.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that on specific dates in October and November 2024, there was no RN scheduled to work for the required hours. Specifically, on 11/2/24, 11/5/24, and 10/29/24, no RN was scheduled, and on 10/27/24, an RN was only present for four hours. The facility's administrator acknowledged the absence of an RN on these dates during a review of the Nurses Schedules. The administrator admitted awareness of the staffing issue and anticipated receiving a citation for this deficiency. The facility's Form 802 Resident Matrix indicated that 69 residents were residing in the facility at the time of the survey, and all 100 beds in the facility were certified as a Skilled Nursing Facility (SNF).
Failure to Prevent Cross-Contamination During Medication Administration
Penalty
Summary
The facility failed to prevent cross-contamination during medication administration for four residents. The deficiency was observed when a Licensed Practical Nurse (LPN) did not perform hand hygiene before and between administering medications to multiple residents. The LPN was seen touching various potentially contaminated surfaces, such as medication cards, the medication cart, computer screens, medicine cups, water cups, water pitchers, resident doors, privacy curtains, and bedside tables, without using alcohol-based hand rub (ABHR) or washing hands. The facility's policy on medication administration, revised in 2017, requires appropriate handwashing or the use of ABHR throughout the medication pass, especially before and after medication administration and after touching potentially contaminated objects. Despite having a bottle of ABHR on the medication cart, the LPN did not adhere to these guidelines. The LPN acknowledged the failure to use hand hygiene and recognized the risk of spreading bacteria between residents. The Regional Director of Nursing confirmed that hand hygiene should be performed between every resident during medication administration.
Failure to Update Level 2 PASRR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to obtain a new Level 2 PASRR (Preadmission Screening and Resident Review) for a resident, identified as R28, to evaluate the need for specialized mental health services after the expiration of the initial Level 2 evaluation. R28 had a history of inpatient mental health hospitalizations and was diagnosed with Paranoid Schizophrenia, experiencing symptoms such as delusions, irritability, and difficulty remaining on tasks. The initial Level 2 PASRR, dated 8/17/2015, determined that R28 required specialized services, including mental health rehabilitation, illness self-management, and community re-integration activities, and was valid for 90 days, expiring on 11/22/2015. However, as of 11/7/24, the facility's Business Office Manager and Social Services Director confirmed they did not have any documentation of a more recent Level 2 PASRR, and the screening agency also had no records of an updated evaluation.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident, identified as R270, who was admitted with medical diagnoses including a wedge compression fracture of the T9-T10 vertebrae, dementia, and hypertension. Upon admission, the resident was alert and oriented to person only. The resident's care plan did not include a focus area, goal, or interventions prior to a fall that occurred on November 4, 2024. The baseline care plan was not initiated until November 6, 2024, which was after the fall incident. Interviews with facility staff revealed a lack of awareness regarding the timeframe for completing a baseline care plan. The Care Plan Coordinator, a Licensed Practical Nurse, stated that the baseline care plan is typically completed within the first week of admission and was unaware of the requirement to complete it within 48 hours. The facility administrator confirmed that the baseline care plan should be completed within 48 hours and acknowledged that the initial assessment does not include goals or interventions for staff to use in providing care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned post-fall interventions for fall prevention for one resident. The resident, identified as R59, was observed seated in her room in a wheelchair with a power cord for a personal alarm hanging from the back, but the actual alarming module was missing. R59's care plan, which was undated, documented that she experienced falls on two occasions, and the intervention after the fall on June 9 was to provide an alarm on her wheelchair. Nursing progress notes from June 9 and June 10 documented that R59 was found on the floor sitting on her buttocks with her wheelchair next to her. On November 6, a Licensed Practical Nurse and Care Plan Coordinator confirmed that R59 was supposed to have an alarm on her bed and wheelchair, but only the power cord was present on the wheelchair, indicating a failure to implement the planned intervention.
Unsafe Bed Side Rail Condition for a Resident
Penalty
Summary
The facility failed to maintain a resident's bed side rail in a safe condition, affecting one resident (R12) out of five reviewed for bed side rails. R12 has a medical history that includes Extrapyramidal and Movement Disorder, Left Knee Valgus Deformity, and Dementia, with impaired range of motion in both lower extremities. R12's care plan indicates the use of a bed side rail for mobility, and staff are encouraged to promote R12's independence by using the side rail. However, observations revealed that R12's half-length right side bed rail was loose and leaning outward, with a significant gap between the rail and the mattress, exceeding the maximum safe spacing recommended by the FDA to reduce the risk of entrapment. On two separate occasions, the bed rail was found to be excessively loose, moving back and forth and pivoting towards the floor when touched. R12 expressed concern about the loose rail, stating it had been in this condition for a long time and was worried about it. A Licensed Practical Nurse (V11) confirmed the rail's condition and acknowledged it needed replacement, especially since R12 uses it for transfers. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure the safety of the bed side rail system for R12.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. The incident involved a resident with severe cognitive impairment who hit another resident on the face after the latter grabbed the former's oatmeal during breakfast. This incident was witnessed by staff and another resident, and it was confirmed that the action was intentional. The resident who was hit had short and long-term memory loss, and there was no injury or redness noted after the incident. The facility's investigative file included interviews with staff and residents who witnessed the event. It was noted that the resident who was hit had a history of grabbing other residents' food and drinks, which led to the altercation. The facility's Abuse Prevention Policy affirms residents' rights to be free from abuse, including physical abuse, and defines abuse as a willful act. Despite the policy, the incident occurred, affecting three residents reviewed for abuse in the sample list.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the administrator, as required by their Abuse Prevention Program. A resident, identified as R3, reported that another resident, R2, had grabbed R3's wrist, causing R3 to feel afraid. This incident occurred when R2 entered R3's room uninvited, and R3 asked R2 to leave. R3's call light was activated, and staff responded by redirecting R2 out of the room. R3 informed a Certified Nursing Assistant (CNA), identified as V8, about the incident, but V8 denied being told that R2 had grabbed R3. Another CNA, identified as V3, confirmed that R3 had mentioned the wrist-grabbing incident and reported it to a nurse, although V3 could not recall which nurse. The administrator, identified as V1, stated that no abuse allegations involving R2 and R3 had been reported to them until the surveyor's inquiry. The facility's policy requires employees to immediately report any potential or alleged mistreatment, exploitation, neglect, and abuse to a supervisor and the administrator, which did not occur in this case.
Medication Administration Error Due to Incorrect Resident Identification
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not correctly identifying a resident prior to medication administration. This incident involved a resident who was mistakenly given another resident's medications due to a room change that was not properly communicated. The Director of Nursing was training a new Licensed Practical Nurse, who administered the wrong medications to the resident because the nameplate on the door had not been updated to reflect the room change. The resident who received the incorrect medications was admitted to the facility with multiple medical conditions, including Congestive Heart Failure, Atrial Fibrillation, and Type 2 Diabetes. The error resulted in the resident being sent to the emergency room for treatment of an accidental medication overdose. The resident received intravenous fluids, Vitamin K to counteract the effects of Coumadin, and other treatments. The facility's Medication Administration Policy, which requires verification of the resident's identity using two methods, was not followed. The medications administered included Coumadin, Trazadone, Lyrica, Oxcarbazepine, and Atorvastatin, none of which were prescribed for the affected resident. This error was compounded by the fact that the resident was already on a different anticoagulant and antidepressant, leading to potentially harmful duplicative and additive effects.
Failure to Document Abuse Prevention Interventions
Penalty
Summary
The facility failed to operationalize its abuse prevention policy by not documenting identified interventions for five residents reviewed for abuse. The facility's Abuse Prevention Program Policy, dated 11/28/16, emphasizes the importance of preventing abuse, neglect, and exploitation of residents. However, the medical records of residents R2, R3, R4, R5, and R6 lacked documentation of interventions to address behaviors with other residents, which is a critical component of the care planning process aimed at reducing the chances of mistreatment, neglect, and abuse. During interviews, the administrator confirmed that specific interventions were identified but not documented. For instance, after a resident-to-resident abuse incident involving R2 and R6, the intervention was to keep them separated and prevent R2 from asking for hugs, but this was not recorded. Similarly, after a staff-to-resident abuse incident involving R3, the intervention was to remove the snack cart from reach without assistance, which was also undocumented. Additionally, after another resident-to-resident abuse incident involving R4 and R5, the intervention was to relocate the activity cart to a less crowded area, but this too was not documented. The administrator acknowledged that all interventions should have been documented in the residents' medical records or care plans to ensure staff awareness and implementation to prevent further incidents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 175 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arcola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Tuscola | 7.5 mi | ★★★★★ | 6 | 0 |
| Arthur Home, The | 9.6 mi | — | 0 | 0 |
| Hilltop Skilled Nsg & Rehab | 10.5 mi | ★★★★★ | 4 | 0 |
| Odd Fellow-rebekah Home | 13.8 mi | ★★★★★ | 20 | 0 |
| Charleston Rehab And Nursing | 14.7 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.